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tv   Book TV After Words  CSPAN  December 10, 2012 12:00am-1:00am EST

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and west into western massachusetts and syracuse that's the audience sort of circumference that we work with. so we go back and we find a general population so proud of the connection to henry james and bret harte and just a little bit further east to emily dickinson and a little bit further south to say hi to an old friend walt whitman they have this sense of the cultural heritage.
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it helps to amplify the writers sense of being a part of the larger story which is very important. it is a whole sense of the literary tradition. so there is this rich ground that is here already and then the writers institute comes in and becomes a begin debate could begin -- beacon and resources nothing else and the rest of that sounds too high but it becomes something that feeds the whole system. it gives fuel, fuel to the fire of people's imaginations and it's very rewarding to see that, to encounter that and to see people in the writing workshops to catch fire with their own creativity because the have been given stuff to work with. they've been challenged by
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excellence. ..
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>> tell us about the reasons you decided to write the book and your findings. >> two main drivers that led me to write the book. number one, patients tell me when they come to the hospital they feel like they're walking in blind there's this giant system they don't know how to evaluate. and when i ask my patients, why did you choose to come to this hospital, i have gotten answers like the parking here is good. we can do better than that. this is one-fifth of the u.s. economy and competition seems to be wrong level and patients frustrated. the other reason i wrote the book is doctors are getting crushed right now. they have declining medicare payments, they've got increasing overhead. hospitals have more expenses. now practice rates are going up. the burnout rate in healthcare is 46%.
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doctors are getting crushed and i felt like we needed a voice and it's okay to talk to the general public. >> host: you make the point that medical mistakes are the third leading cause of death in the united states. that's a shocking figure. can you talk about that? cincinnati was shocking even for me as somebody interested in this field of quality to see it put in that way. medical mistakes, number three. we kill as many people from medical mistakes as we do from car accidents and other -- three, four and five causes of death in the u.s. i guess i never really thought of it that way 'we don't really talk as openly and honestly about mistakes as we should in our profession, to be very clear. you think about, number one, heart disease, number one cause of death in the u.s. we spend a heck of a lot of time
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and money in heart disease. and cancer, and medical mistakes, it's number three, there's not really a medical mistake problem in the u.s., and it we're just starting to except says is something we have to start talking honestly about. >> host: so, we know there's tremendous care that's received here in the u.s. certainly at the institutions you trained at. but this concept of quality and disparity of quality and you got interested in it during your doctoral program at harvard. we talk -- can you talk about how came to what and where did the field come from? >> guest: i think is just started to be recognized as a field when i was a student. a right time-right place kind of
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thing. i had this frustrating experience with patient of mine that i was assigned to follow. her name was mrs. bank and she is in the opening of the book. she really didn't want anything done for her cancer, which had spread all over. the doctors clearly wanted to do something. they essentially bullied her or talked her into it. they overstated the benefits and understated the risk, something we know from research happens-especially'll those that do procedures. is just didn't seem right to me. it seemed as if this profession wasn't telling the truth. it seemed as if the profession ol' medicine has long trade from its original mission and heritage. it's not why i went into medicine, and i, quite frankly, quit. i started school at public health where i met david bates. >> host: you were in medical school and you decided you had had enough and you went to
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school of public health? >> guest: yeah. i basically explained what mrs. banks wanted at our morning con fresh. they tore me upside-down for explaining to them that she didn't want the procedure done. they basically implied, didn't matter what she wantses. this is what she needs. and this was to me a sign of a culture that i had observed sort of from the outside but didn't want to be part of, and i quit medical school. and then i started graduate school for public health because i had heard of a tract where you can focus on quality and there were people now interested in medical mistakes, and for the first time they were describing studies where they were looking at hand writing resulting in patient harm. it was a radical concept at the time. david bates put a big study out and describes the head of one of the largest doctors organizations in the united states, calling him and basically saying, what are you doing this for? this is not a problem.
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and i realized that we have had these explosions of knowledge in medicine, but we have not coordinated care, and all these services that we have end up having so many cracks that the cracks are as harmful as the diseases that we're treating, and you got to step back and ask, you know, are we hurting people overall? i mean, on a global level? what are we doing sometimes. and of course, now we've got the institute of medicine report saying 30% of everything we do may not be necessary in health care. when we step back, 30% of all the medications we prescribe, the tests we order, the procedures? this is something i think which is for the first time really being called out as a problem. now, people out there in the general public have been saying for a long time, we don't like the closed-door culture of medicine. we find medicine to be an
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arrogant industry. we feel like we don't connect. i remember in medical school being told that a nose bleed was e help by stacks sis, it's like a whole different vocabulary. and that disconnect. has, i think, created a issue with our trust in the public and this issue of overtreatment now has further strained the public trust that medicine -- it's a great job, great profession. you're in health care and every day you see folks have tremendous results. the byproduct of phenomenal advances in technology and the art of medicine as compassion. but when we have thin constitute of medicine saying 30% of the time we miss the mark, we have to study this. we have to make it a discipline of science and say, how can we look at this like we would look
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at cancer? where are the cracks? where are the mistakes and how can be streamline care, and that's why i decided to write "uncombattable." >> host: that statistic of 30%, problems of quality, waste, variability, is a stunning statistic. why do you think that -- you mentioned culture a little while ago. what is it about the culture of health care where those types of activities have been allowed to go on for such a length of time ? if you look at any other industry, 30% waste or 30% error rate, really would be unacceptable. how does that occur within health care and medicine? >> guest: it's a great wonder why people tolerate 30% waste in health care but they wouldn't tolerate it in any other industry. i talked -- the average income
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of an american in the united states has gone up 30% over the last decade. the increase in healthcare costs they're paying have gone up 68% over the same time period. essentially we've offset increases in income with increased health care costs. so you wonder why we tolerate this? i talked to business leaders and they say every contract we pay we have some metric of how well they perform, excepts for one, health care. we keep throwing money at it. the patients say the same thing with their premiums and high deductible. what are we getting for our money? there's this culture of medicine that has respected the art of individual autonomy, but at the risk that some best practices never got standardized. in my own field, pancreas auto transplant, where we take a plan
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contracts out -- pancreas out of somebody, treat the cells and give it back to the patient. we need a laboratory to treat the cells. medicare at one time paid a bonus $20,000 payment to hospitals to do this, and it became a very profitable business. now we have a laboratory at johns hop kins in the operating room, and we have the patient asleep under anesthesia, take the pancreas out, treat the cells, give the cells back right then and there, same operation. hospitals across the country started doing this operation, taking the pan career at out but because they don't have a laboratory, put it into a cooler, send it by jet to another city, have it treat at another facility in another city or state, have it flown back and then cut the patient open up again for a second operation. why would anyone have that procedure done? they don't know about the other options. now, i'm not talking about tiny hospitals. i'm talking about two of the
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u.s. news and world report top ten hospitals in the country do this? we've got smart people, good people, working in a bad system where these financial incentives lure people to do things that just aren't right. and i think if hospitals are accountable for their results, if the patient satisfaction scores, the patient outcomes, the complication rates, the volumes, the readmission rates, all the basic metrics are health care performance that doors are endorsing as valid. if they were available to the public, people could choose where to go based on who performs the best like any other free market, and like any other free market uses to reduce waste in their field. >> host: so, the issue of patient choice, about where they seek care and certainly in the health care literature and discussions amongst leaders for a number of years, and where many people advocate that if
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indeed patients had the able to see the quality data, to see individual physician performance, hospital infection rates, they would naturally gravitate to those institutions. there's another school of thought that says, you can put all the information out there but that won't happen. patients gravitate to a new reference in your book, where patients seek their care, i go there abuse my mother was born there, or because it's two miles from my house. talk to me about the balance there and how, if indeed quality is a factor, how do we get patients informed as to how they can seek this information and really will it make a difference in where they seek care? >> guest: i've got some patients that tell me, doc, whenever -- whatever you want to do, you just tell me and i'll do it. totallal blind trust for the doctor in and the system.
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but more and more patients now want to know the options, want to know if something can be done minimally invasive. if they really need to take a medication or if there's a wholeis stick or preventive means, do physical therapy to avoid something. they want to know now. we have an informed public and increasingly we're seeing that. now, one critic of the book told me, if you put stuff out there, people will never use it and it won't reduce healthcare waste. well, four weeks after the book came out, a study in the journal of the american medical association showed that when there was public reporting of heart procedures -- week talk about extents e extents and an n angie ograms, and a report showed that public reporting reduces waste and has no
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impact -- patients did just as well. so i think increasingly we're learning about the impact of public reporting, and, look, all of us know doctors who should not be practicing. i mean, one national conference i was at, asked the audience, how many of you know of a doctor who shouldn't be practicing because they're too dangerous. every single hand went up, and i think because we all recognize there's going to be some bad apples that are going to respond to financial incentives and that there's little accountability in general in health care, a hospital about seven miles down the street from my hospital, had a doctor put in at least 500 unnecessary heart stents. now, if those procedures would have been recorded and given to the patient on a thumb drive as i advocate in the book, that doctor wouldn't have gotten away putting in stints? arteries that were never blocked there would have been some
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oversight, just like when he have speed traps with cameras at an intersection, everybody follows the law. the compliance rate we're trying to get everything to follow the speed element for decades has been horrific. since we have had automobiles, we have been trying to do education, education doesn't work to get people to follow the speed limit. what works is when somebody sees a camera or an officer on the side of a road. then everybody is compliant. i think we in health care have a lot of room to increase accountability, and i think it will really restore the trust that's been broken with the general public. >> host: let's go back to the culture question again. i was rivetted when i was reading be book about your account when you were in that room and everybody raised their hand. in fact, as you describe it, you were hesitant at first to raise your hand, and there was a senior physician next to you who kind of looked at you and said, really? you don't know anyone? and then you did.
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but what about the culture of medicine do you think has led us to this point of where we actually know that harm may be occurring or have a sense of it, yet we have gotten to this point where people are afraid to speak up, afraid to criticize their peers or the institution. you make a point a number of times in the book that -- and then actually your opening chapter, where you talk about the fact that go to where the people in health care, the doctors and nurses in the hospital seek care. how does the culture, if you will, proliferate what you have been talking about, or the public, how do they seek that information out? >> guest: you know, i once told a friend, the best way to find out about the quality of a hospital is to ask an er nurse who works there.
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a nurse knows more about the quality of the hospital than probably anyone else there, and for that matter in any industry, frontline worker providing the services, be it sales or creating products, probably knows more than any of the administrators at the institution about the culture. the reason is that culture drives everything we do. in economics there's this phrase no one has ever washed a rental car. they don't own it. so why -- and the sense of owning the delivery of care is of critical importance in health care. that's what bothers me about seeing the statistics now that 46% of us doctors in the united states are burned out according to the mayo christianic. did a study three weeks ago. when we have 46% of frontline providers in any industry burned out, of course the quality is going to be variable, of course mistakes are going to happen. of course people are going to fall through the cracks. when people don't feel they own
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the service, that -- docs tell me when guy to conferences and speak, i often know how to make health care better at my institution. i know how to make the care safer. i just don't feel anyone listens to me. i don't feel empowered. and that, i think, is one of the great divides right now in health care in the united states. increasingly, we have some doctors saying at some facilities that there's a chasm between this. s and their unitmark, between themselves and those making the policy or calling the shots. they don't feel empowered and we're seeing more variability because of that. >> host: you talk in your book about administrative crackdowns, if you will, where you get providers of care and senior administrative leaders working a little bit more together, or getting the administrators out
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from their cloistered offices. talk about that and the value of that as well as its impact on the quality and safety. >> guest: we all want the same thing. doctors, administrators, insurance companies, policymakers, there's an astronaut from outer space who was asked, what does the middle east look like from outer space? and he astronaut said, you know, there are no lines when you look at it. the lines are man-made. and that's what is going on in health care. the lines we have made in health care are man-made. we all want the same good for the public. we've got good people. they're just sometimes working in this artificial system. we tell administrators, make a profit, fill your beds, so they make a profit and fill beds. we tell doctors, see more patients, so the see more parents. we tell surgeons do more procedure and they do.
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everyone seems like they're doing their job, but as don said, it's like the jobs are designed wrong. and we have good people, and when my dad was a practicing doctor, i remember this administrator named ken ackerman who would come down and sit down with the docs and walk down the hallway, prop himself in their office and say, how is it going? what do you need to do your job better? now, he wasn't a doctor, ken ackerman, but the doctors on the staff said he was the administrator in a white coat. that's how they came to nickname him. he was in touch with the frontline provideres. and you see in all kinds of industries, be it lehman brothers, a large corporation that is delivering a service that's multinational. when the administrators lose touch with the frontline folks, that's when bad things start to happen.
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that's when the k accountability becomes a problem, because there's no transparency, and that was the impetus for writing my book. >> host: i'm struck by the fact if you want to know where the issues are, as you describe, you go to the frontline and talk to the providers, go to the ed, go to the operating room nurses. why do you think that we've -- in many hospitals, perhaps become -- there's been a separate differentiation or divide, if you will, between administrations, doctors, and does it have anything to do with innocent? if you talked earlier about -- anything to do with incentives? what do you think? >> guest: i have seen both extremes in the united states, and i talk about both extremes in the book. i recently learned of an emergency room that was built --
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that was free standing with no hospital attached to it. can you imagine, having a heart attack and you go to the emergency room and they don't have a hospital to put you in they have too slip you across the lake to go to another hospital because that's their associated hospital. they admit patients at? this happens in the united states. this happens, and you see these doctors saying, this isn't right. and even sometimes the administrators will say, yeah, we know it's not rational, but that's the way we get paid. we get pate more for the emergency room visit than private care, and you realize, when thinks are disassociated, the care gets dangerous. then you see times when they're in harmony. you see when there's transparency of infection data, how the administrators talk to the individual providers specifically about infections. what do we need to do to get our infections down? this is a model of management for any industry. in the new york transparency
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experiment, when heart surgery outcomes were publicly reported, i tell a story that mark chapman described where they actually had administrators walk into the unit and ask the doctors and nurses, what do we need to do to get our mortality down? they're asking nurses, why is our complication rate high and how can we decrease it? you don't see that level of common mission around reducing complications except when everything is aligned, there's transparency of the data, there's accountability at all levels for the performance, and people own the system. and i -- you know, i remember hearing the story of a nurse saying, we've never seen the ceo here in the cardiac icu except when we had public reporting of heart surgery outcomes, and you realize, these are old fashioned concepts here. these are american concepts. they're not republican or democratic concept.
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transparency is an american value. we expect it of the white house, we expect it of congress, we expect it of wall street. sarbanes-oxley will have a ceo go to jail if they misreport their earnings for a company. yet in health care it's almost like an island, almost as if you can misreport infections or there's not that level of transparency, and we treat it differently. we got to start treating health care like we do any other business, to reduce the waste and reduce the costs for everyday americans. people are getting crushed right now. they're essentially paying for all of their health care with the exception of catastrophic care. it's becoming a two tiered system we're seeing primary care doctors say you just pay us a couple thousand dollars a year, we're going to take care of you but with house calls you have my cell phone you call me at night, i'll -- it's medicine the way they like to practice it, the way we all dreamed of practicing
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medicine. it's health care the patients always dreamed of getting, and they're rejecting, they're revolting against this bureaucratic regulatory system that involves fighting insurance companies and all the hassles doctors are getting crushed with right now. >> host: so, let's talk about the leadership and the role that leadership plays. i loved the story that you tell about bill brady. i use the that story myself. but talk about that and the role and the example of that story and what you think it means to senior leaders in health care. >> guest: you know, i find that many times everybody wants the same thing but there's just sort of a breakdown of communication, and when bill brody walked through the icu and started talking to nurses -- >> host: tell hour viewer -- >> guest: bill brody was a time president of johns hopkins
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university and was part of this initiative to have all the executives adopt a unit and many of the executives at hopkins adopted a unit, and icu or ward or clinic or operating room area, and they would meet with the staff -- and we still do -- and say what are the safety concerns here? how are you going to harm the next patient. they anticipate what is going to go wrong win we have a medical catastrophe, and they happen every year at every hospital in the country. have medical mishaps every year, and these discussions create sort of an anticipation that allows people too redesign and reengineer the hospital system, to make it safer, and you don't -- the employees, the staff and the nurses, they feel valued. people listen to them. and when we've got 26% of doctors saying, they're burned out, they don't feel valued, getting crushed with malpractice and insurance and premiums and costs and having to fight with
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insurance companies. feeling value goes a long way and not feeling valued by your hospital or leaders, is a serious way to alienate the very people responsible for safety and creating a safe culture. >> host: so, for those of us who are leaders or ceos of hospitals, et cetera, what role should accountability and transparency play in the way that we conduct or daily business? what's your perception and where can we improve? >> guest: seems like it's the old guard of the establishment, or if you will, the corporation that resists the transparency. when you talk to the individuals, the people, that the moms, the parents, the -- those who take care of patients, the doctors, these are all people who are also hospital administrators.
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they want the best things. they understand the value of it. they're smart people. they are pushing this. and we're seeing this transparency revolution not driven by patients, ironically, but driven by the very doctors and administrators and organizations that see the waste in health care, it bothers the heck out of them, and they want to do something about it. and we're seeing -- the surgeons, society of thoracic surgeons, organizations, leapfrog -- all these organizations rally together to say, we think it's the right thing to do, to be transparent about what we do. we're proud of our results. gottinggot nothing to hide, ande perform well, the public should see it. if we don't, the public should see it anyway because we're honest and transparent. i once ordered a cat scan, got done on the wrong patient. and as soon as i learn about this i ran the patient's bedside and said, i'm sorry you didn't
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get your cat scan because there was a mistake. i'm going to make sure you get it done right away to the other patient i said, we're sorry you got a cat scan that was intend for someone else. i'm sorry. we'll share the results. the parents were not angry like i thought they would be. they looked at me with a sense of appreciation, thank you for being honest with me, doctor. and i feel like patients a lot of times just wont honesty. they want to be treated with dignity. they want to be treated like they would in any other business. and i think that's what people are hungry for in health care, and that's what the organizations and the leaders in health care are saying we need to provide to patients. we did a research study recently that looked at the number of national databases that follow hospital performance and patient outcomes. in my own field of pap career as extras plant patients there are databases we report our outcomes
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to. there's a registry. they follow all the outcomes of the different hops that do this. but the public has no access to this information in our research study we found there are over 200 national registries that track hospital outcomes. only three make their data available to the public. most are funded by taxpayer dollars in some form. i think we as a society are starting to ask the questions, do we have a right to know about the quality of our hospitals? and i think we're seeing leaders in health care step up and say, yes, we do. >> host: so, you've raised some provocative and compelling issues here in your book, and it really has, i think, been truly illustrative in terms of things going on and made "the new york times" bestseller list, et cetera. what -- i'm interested to know
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the comments of your peers in this, both perhaps younger physicians, older physicians, you've used the term "old guard." you talk about this. many people are recognizing it. talk about what impact it's had in really how people are feeling and the feedback you heave been getting. >> guest: i've gotten thousands of letters, many of which are hand written, tens of thousands of e-mails that say, you know, my mom died because of a medical mistake. we didn't feel we really were part of the process. we didn't feel we were given all of our options. we think there was a mistake or we know there was mistake. thank you for sharing this story. and it's almost as if everybody has a story. i've got personal accounts here of people i know and are close
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to that had suffered from medical mistakes. everybody, it seems like, has story. it's number three cause of death in the united states, medical mistakes. almost seems like we all know somebody and i think there was a general appreciation for talking about this openly and honestly. the younger doctors in particular come from a disgeneration. the medical students nowdays have very little tolerance for not telling the truth in any aspect of life. they just insist on transparency in all aspects of their living. and then there are what i refer to as the old guard. those that say, i'm an expert in medical mistakes. we shouldn't be talking about this with the general public, or, there was one individual -- his response the book, said there was a typo on the inside jacket of the cover. we're trying to say 30% of health care is unnecessary, and
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the response is, there's a typo? we're trying to say medical miss stakes remember the number three cause of death. the response is, there's a typo? of course there's going to be different responses. health care is a very emotional issue. look at the way the politicians have divided the country and polarized the subject into sound bites. health care is complex. the reality is there are good ideas on both sides of the aisle and we need to talk about common sense solutions in health care. all the different ideas we hear about from politicians are really centered on how to pay for health care differently, how to fund the broken system. we don't -- if we don't have the talk about financing the broken system. you have to go on to how to fix the broken system and that's a fundamental discussion which gets to the base of transparency, patient outcomes, patient choice and patient
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empowerment. i've lived in d.c. for a while, and i know politicians are not going to fix health care permanently. we doctors aren't going to do it. insurance companies are not going to do it. it's going to be the patients and we have to give them good information. it's 60% of new yorkers are looking up a new restaurant's track record and ratings before they good there. why do they have to walk in for their health care blind? about what a hospital's c-section rate is or infection raid or bounceback rate or how many hip operations they do, or how many knee operations they do. if you have lyme disease, do you want to go to a hospital that you're the only case in five years they've seen? or do you want to go to a hospital that treats 50 cases a year? these are basic things the public demand in any other industry, and i think we can provide these things in health care to through more transparency. >> host: that leads me to -- you
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use the term fred flintstone care in your book. and talk about that, and you seem to -- your thoughts around how that plays into what you just described, which is, we have 60% of new yorkers who will go online and look at the restaurant review but they'll just walk right down the street their hospital without really doing any due diligence, et cetera, and how does that kind of fred flintstone care in the culture of medicine play into that? >> guest: i am constantly flabber gasted how patients will walk into a doctor's office and the doctor just will not mention the superior option to the patient. i think sometimes because they're worried about losing the patient to another doctor. you get paid a lot of money based on the quantity of what we do. that's got to change. we've got to be paid based on the quality and our outcomes. we have to get away from this
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heavy volume oriented way we finance our healthcare system. we are just incentivizing people to overtreat and when we asked doctors in the survey why is this overtreatment epidemic so broad, they say because we're so heavily innocent vices -- they don't say themselves -- other doctors are heavily incentivized and there's malpractice concerns and other things. they have the answer. a lot of the doctors out there have the answers on how to address this problem of medical mistakes and overtreatment. i have talked to doctors almost every week that say, i'm getting text messages and e-mails from my superiors to do more operations, and i feel like i'm doing the right thing for my patients. i'm doing all i can. they don't like that. that's not the type of medicine, not the profession they went into. and i think we need to start thinking about how patients can get the best options by eliminating these heavy
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incentives to underrefer. there are patients that i met, rotating as a resident, that were not told there's a superior way to reconstruct the breast after a breast removal. because the local plastic surgeons don't do it that way. they do it another way. the research and the literature clearly show it is infear you're. it's still a standard of care but there's wide variations. in my own field of pan career us a surgery, if you have a small pancreas cyst that needs to be removed, the patient walks into one hospital or one doctor's office, they'll have a big incision, the tail of the pancreas removed and their sleep. they walk into another doctor's office, they'll have a small minimally invasive key hole indigs and have the tail of the pancreas removed and not remove
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the vaccine. we're talking about removing or not removing the organ based on which door you walk through. they're all go doctors, good organizations, radically different ways of doing things. removing a colon. now, there's two totally different ways of doing it. minimally invasive and through an open incision. and some say there's -- you do it either way. we have a new england journal of medicine study that is over ten years old that shows the minimally invasive is better and it's common sense it's better. yet the wild west of medicine would have it that only half the patients that are great candidates for the minimally invasive will ever have it done that way. >> host: you used the term the wild west of medicine and you talk about the need to have a new sheriff in town. so, talk to me a little bit about this concept of the new sheriffs in town or accountability or holding people responsible, and how that
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balances with what we frequently hear when we try and move forward with standardization or accountability as to the art form of medicine. how do those two things kind of play out? >> i get the art form of medicine. most of the patients that come to see me are complicated pancreas tumors -- my own area of expertise -- and just in my field, i see these complex cases where patients are told, there's nothing that can be done at the other hospitals, and then they come to me and we say, yes, it's high risk, we'll take it on. these are the risks. if you want to go for it, we'll go for it. and they were right for a time ta minute. we can't make our outcomes transparent. it doesn't appropriately adjust for the high risk nature of the cases we take on here. i agree 100%. matter of fact doctors were right to lead the opposition to
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transparency because if we simply make the raw data transparent, we could punish doctors that take on the noble high risk cases and reward those 0 who discriminate against them. we would actually create reverse incentives. now the doctors are saying we've got valid ways to measure quality. we've created these measures. we've endorsed them. we monitor them with our own national registry by the doctors groups. we think it's the right time to make this available to the public -- and this is an exciting time in health care and with transparency. we have consumer reports now, partnering with doctors groups to make the national registry outcomes available in easy to understand ways so patients can look up with an app what the risk adjusted performance is of a heart surgery center in their community. this is, i think, the future of health care.
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it's an exciting time. it's a revolution. i've sort of become an observer or a recorder -- report on the subject. i'm not the leader of the transparency revolution in health care. we don't have one leader. this is a truce, something we believe in and we're as passionate about as the art of medicine itself. >> host: you talk about where perhaps a decade or more ago, doctors protected that information because it could be misinterpreted, if you will. and then there's been this evolution of thought toward transparency, partnerships between consumer groups and physicians. if that is the case. what impact has that had in terms of our overall levels of falling safety efficiency and mistakes? this movement has been going on for some time, yet you cite some
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really challenging cases and statistics going on. what's your sense of how things have moved and where is it going in the future? >> guest: that's a great point. we've gotten burned with transparency. we have had systems that are local some small. either the patients haven't knowny to be the information. unless there's a central site like hospital safety run by leapfrog thor consumer reports. there's no sort of master dashboard, then we're not really informing the public, and we're not really guiding them. the other thing is, a lot of times we created so many loopholes doctors have learned how to game the system, and that's what happened in the u.s. with the heart surgery program. there were many successes. we saw for the first time ceos and doctors focus on a common mission to reduce certain complications after surgery. but ceos were saying, here, how about a dedicated
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anesthesiologist who specializes in heart anesthesiology, and a doctors are saying, yes, that's what we need. there's a tremendous teamwork we saw with transparency. but the system wasn't perfect, and for the first time now i think we're seeing doctors groups better define what is a complication. they are using independent nurses at a hospital to track the outcomes. early versions we would just ask the surgeons, what's your infection rate? well, of course we would understate our complication rates, and it was a uniform bias. it's just the nature of discussing your own performance. and i think now there's an exciting opportunity, we've got organizations and doctors lined up to say, look at all these sites we can pop late with information. the affordable care act tried to push some of this forward. i believe there's a lot more we need to push forward.
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readmissions are going to be available for the public, and for the first time ever this year people can look up a hospital's infection raid on the national medicare master site hospital compare. for the first time they're going to be able to look up hospitals bounce-back or readmission rates, people that just come back into the er after they go home. these are what doctors generally consider to be valid -- not perfect -- valid ways to measure quality. and we're going to see consumers rally around them. we're going to have to fix them. they're not good. they're not perfect. we have to make them better. we have to refine them, revise them, and make them more risk adjusted and valid. but it's a tremendous time route now -- right now in health care and frankly, we need fresh ideas in health care. we've been talking about the same stuff for years. we need some new idea. >> host: this field of quality and safety in health care is a relatively young field. you talk about the need for patients and consumers to get
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actively involved. you reference that doctors can't do it. regulators can't do it. politicians can't do it. but that patients have to do it. talk a little bit more, if you will about the role that patients need to have? because today i'm struck with the fact that if i go google something on the internet, a certain disease, or treatment, i will get hundreds, perhaps thousands of different sites to go to. and one thing i keep hearing from patients is they have difficulty navigating that. how do they know what the high quality data that's out there exists -- you referenced a couple. but if we're going to ask patients and consumers to play an active role and help us move forward and change this system, how do they navigate that? what's they're role within that? >> guest: that's a great question. there's probably even with all these great web sites out there, consumer reports, hospital
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safety scores, hospital compares. looking at infection scores. even with all these new web sites being populated with more and more information every year, nothing substitutes for a great conversation between you and a doctor or you and a nurse in the doctor's office. there's something to be said for the patient that does the research on google which, by the way, is 92% accurate for health information we have done that research at johns hop kips, people type in their operation, their condition, their medication, and what they're looking at in the first hit is 92% right on. and there's something to be said for people who do that. bring that into the doctor's office and have that conversation. what i often tell people is if you're going to have something major, like an operation or you're going to start taking a medication every day for the first time in your life, or you don't know what you have wrong with you and the doctor can't
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figure it out, get a second opinion. get a second opinion. those are times when we have to remember that the stats show, 30% of second opinions are different from the first opinion. we are human beings. even in my own area of expertise, i will run things by a partner or an expert somewhere necessary the country. somebody has seen a different variation or a different presentation. it's no substitute, i think, for good conversations with doctors. doctors are as frustrated with the broken healthcare system as the patients are. and i think when we see ourselves in the same boat, i think we have a certain appreciation. i tell medical students, treat every patient like it's your own mother or father. and i think that's a good guiding principle that was taught to me. >> host: so, just to follow up on that, you throughout the book
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you talk about the importance of teamwork, and you just referenced it now. i'm struck with the need for teamwork, if you will, as we move forward in healthcare reform, as well as starting to tackle the issues you have identified. one talks about the fact they we have many moving parts, many players in health care, if you will, where we have many people who are responsible but little accountability overall. how would you -- first of all, two questions. one, what's the role of teamwork in the care that we deliver and the importance of that? what's the role of the patient within that? and how can we move forward with all the different groups? physicians, insurers, regulators-patients, to try and resolve some of these issues.
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>> everybody seems to recognize that teamwork is a critical part of delivering safe and high quality care. yet we've never even measured it for the longest time. it's almost as if in a factory you know there's one part of the assembly line that shows shoddy, it's off and on unreliable and it hurts the entire process, and yet no one really looks into it. there's now a survey that measures the quality of the teamwork. it asks everyday providers, would you go here for your own and they do you feel comfortable speaking up? do you feel that you're part of team or do you feel your concerns north being heard? it turns out that these results now are being followed and tracked, they're just not available the public. the government even issues a survey on its web site. its makes it available for a free download for hospitals and it collects a lot of the information, yet there's no real accountability around that.
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that's one simple thing we can do differently. but often times when i talk to docs and nurses, they will say that when the teamwork is good here, everybody is happy. when the nurse turnover rates are low, that is, nurses are quitting and being hired at other institutions -- when the turnover rate is low, that's just feel they own the care better. it's a better place to work. and i had my near miss, if you will, and i described in the book, a time when i harmed a patient with a mistake i made. i described a time when i almost operated on the wrong side. >> the nurse spoke up. >> guest: the nurse spoke up and that's what saved the patient having the wrong site procedure. i remember the day. it was crazy busy. i was shuttling from the icu to deal with a quick emergency, came back to the operating room, our team had sort of prepped the
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patient and they prepped the wrong side. it was a minor procedure, but it would have had catastrophic consequences for me, and for the patient. and it just -- one of these things where you realize, it's a team sport, and more and more we are hearing the nurses say, you know, if we can have more teamwork, less disruptive behavior -- we have a study now, the archives or surgery report, 90% of nurses and 40% of doctors have witnessed disruptive behavior in the last three months. we can do a lot to improve the teamwork in a lot of hospitals, and a lot of it starts with the peer respected leaders. >> host: so the work you did, brian sack ton and others, talk about the issues of culture, the importance and importance of teamwork, and i'm struck by the many examples that you've given and i've heard through the years, of the importance of the
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members of the team, perhaps not the physician or the surgeon speaking up, and you describe one in your book. what has to happen in order for that to become more common in the culture? especially in procedure areas where perhaps we equate the operating room to what happened flying a plane in and the needs -- where aviation went through some of these things, really decades ago and what they took away. from your perspective, hough does that teamwork really get enhanced moving forward and what starts it? who has to start it? >> guest: you know, it's one of those cultural traits that changed over time but we need it to change faster. sometimes i think of the hierarchy of met sane similar the hierarchy in military. we have rules and procedures, ways of doing things, unwritten
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standards we n never go above our superior's head for anything. you know, i think we can be more honest and open about the problems in health care, and we can redesign the way we talk in the operating room and the healthcare setting in the clinics and hospitals. when we developed the check lift for the operating room -- this is after peter worked in the icu and said we're going have to a daily goal sheet. and popularized -- led the world health organization group. we presented our experience the group and it became much big irthan we anticipated. the number one priority that we made in the chick list was making the first item going over the names and members of the team, going over their roles, and it's just a simple introduction, and when he led our committee at the world
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health organization, he was particular that be the number one item as well. we all saw the value in making introductions just a simple statement of your name, and what role you have in the team, to be a critical part, not only just to be friendly -- let's face it, that's nice but that wasn't the goal. it was to empower people to speak up. actual work place you have a conference room and you're sitting around for a meeting, and you have to say something in the beginning or present something or speak up for any reason, it's easier to speak up again. it's almost as if the first time you speak up and say anything, you're activated and that's what we try to do is activate every member of the team. >> host: so the team members are activated. what about the patient? do we want the patient or family members to speak up? >> guest: absolutely. it's amazing the amount of information patient family members add to our understanding
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of the patient's condition, and by and large, if you can join family member when they see their doctor, go with them. and this new program called open notes that allows patients to instantly see their doctor's note when they see a doctor for a visit, has been tremendously successful, not because it's going to fix health care. let's face it. it's innovation like that is not going to solve our healthcare crisis or cost, but there's this disproportionate amount of enthusiasm for it in part because of what it represents. it represents the professional of medicine bridging the divide and saying, hey, you're part of this, and it's the doctor sharing with the patient in an open and honest way, i want you to see what our plan is. i want you to see what i wrote down. even add a line tonight it you like. say at the bottom, i agree, or there's a mistake, or i misspoke, or this i b.s.
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i don't think this represents me, and that will be part of the patient's record. one time i had a patient who i was seeing and she was asking about abdominal pain, and she asked me a question that was a little bizarre, something about, there's a certain type of ben and jerry's ice cream over another type caused this kind of pain. i told her, no, it doesn't. it's unrelated. and then she at the end had this sort of suspicion, and it turns out she was worried i wrote in the chart that she is a psychoor crazy or something. i said, no, here it is, and when she saw the note, the bond of trust was almost instantly restored. so. >> host: we have a couple minutes left. a few last questions. we have talked about the role of leaders leaders and christian there are clubbiccans. what role do boards have? there's been a movement about getting them involved. >> guest: first of all, very disappoint i saw the department
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of hhs change this new rule that a physician should be on a hospital board. there was an attempt to make one physician -- at least have one physician on a board of the hospital. and they overturned this intended rule at the last minute, and it's a great disappointment to a lot of doctors. doesn't make sense, a lot of patients the same. but the broaderrer subject of a hospital board's mission -- when the hospital boards and the good ones are focused on the hospitals outcomes -- when the boards are looking at the performance with metrics, when they're have a dashboard, hospitals do very well and the boards are doing a great service. when you're looking at it like a pure business and just the bottom line, then that's when the culture becomes very bad. >> host: we just have a minute or so left. just to wrap up, this book has had a tremendous impact. you've gotten a lot of press on it. are you
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